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REC=]VEDroo P7 ? - :•a SAN JOAQUIN COUNTY JUL 3 ® 2014 ENVIRONMENTAL HEALTH DEPARTMENT '•�+ LOP ' 1868 Hazelton Avenue, Stockton, CA F3`$dSQ*tENTAL HEALTFPITE MITIGATION ..... ;,.P Telephone:(209)468-3147 Fax:(209)468-3433 Vt/eb.�.�ilp (,Id UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES.j YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Heelt�Department Site Location 7675W.11th Street Cross Street Poplar '57Trac ,CA y Properly City/State y Zip APN 250-140-12 Owner Yvonne Miller Address P.O.Box 366 Trace CA 95378 City/State y Zip Phone 209-835-3466 C-57 Contractor Greg Drilling Address 950 Howe Ave. Cit/State Martinez,CA Y Lic `185166 Phone CM-113^58+0 Consulfant/Sub Cntr Cardno Address 1117(_one Palm Ave.,Suite 201 B CitylState Modesto,CA Lic 95351 Phone 209.579,2221 Billable Party Cardno for Yvonne Miller Address 1117 Lone PaIm Ave.,Suite 201B City/State Modesto,CA Zip 95351 Phone 209.579.2221 GIS Coordinates:X 37.740 Y-121.400 3 7• —!zl ytb3� CONSTRUCTION WORK TO BE PERFORMED: — ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) El SOIL BORING IDs D WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le AlrSmrae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dla: COMMENTS:_Cement skirt Gurro ndin0 well box Will he replared NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS _ DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALLTHATAPPL �'_ #OF WELL S)TO BE DES T OYED D OVER-BORE DIAMETER OF - INCHES TO DEPTH OF 20-27 FT WELL IDs:_MW 1-9. AS-�. AS-2. DIP 1-3 D PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS D EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:D AUGERS D HOSE ❑PIPE ❑MUSHROOM CAP AT`3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I hava�prepared this applicalt!oA and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,and all ap tfcable C;Oiforfila la Signed _ � i-f Title/Company Staff/Cardno Print Name Charlie Selkow Date 7-A2-N DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 705- It), l I TN 57-1 WORK PLAN DATED J Lt 1.N I C( 201 4� APPLICATION ACCEPTED BY DATE ISSUED L - �!-! I AREA 1�c rf GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST I PR# iso 2 $ x3� `l eou -3n-1 y sR# 2o 2 3So q RO#3 310 3500 PR# 2900 C-57_ WC WAIVER #4-- *- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC A-"iq EHD 29-01 5109112 WELL PERMIT APP